TNF and systemic lupus erythematosus: In addition, difficulty in discontinuing TNF-α inhibitors after initiation could be a contributing factor to longer treatment periods [39]; however, with extended TNF-α inhibitor use, there are risks of adverse effects including development of autoimmune diseases including systemic lupus erythematosus [40] and multiple sclerosis [41], as well as paradoxical sarcoidosis [42].